http://leader.pubs.asha.org/article.aspx?articleid=2278287Model Becomes RealityDuring the 1990s cochlear implant technology advanced at a rapid pace. The time seemed right to try to normalize the educational experience of deaf children who, with the use of these new technologies, possessed an unprecedented ability to access the listening environment. While some young children with cochlear implants quietly ...2005-03-01T00:00:00FeaturesNancy Mellon

During the 1990s cochlear implant technology advanced at a rapid pace. The time seemed right to try to normalize the educational experience of deaf children who, with the use of these new technologies, possessed an unprecedented ability to access the listening environment. While some young children with cochlear implants quietly thrived in mainstream schools, questions remained about whether newly implanted children would be able to acquire language in the context of a regular education environment, given appropriate support. We believed they could and set out to create an optimal environment to do so.

I had a personal interest in seeing children with hearing loss develop language successfully in a mainstream environment. My youngest son, Will, had been born with profound deafness in 1992. Will received a cochlear implant at Johns Hopkins the week he turned 2, and learned language among friends with normal hearing in a private preschool in Washington, DC with the help of a team of supportive professionals. Will is now in 6th grade in another mainstream private school. He is a fluent user of English who loves reading, history, sports, movies, music, and talking on a cell phone. I believed that other children born with deafness could share his success if given an optimal school experience, ideally a place where all of the services needed by young children with hearing loss could be provided under one roof.

Curriculum and Adaptations

The River School opened in January 2000 with five children and 10 faculty. Five years later the school is serving 168 children-22 of whom have hearing loss and use hearing aids or cochlear implants-between the ages of 18 months and 3rd grade. The faculty of 50 professionals includes specialists in art, science, music, library, dance, drama, and physical education. The school faculty also includes 15 SLPs and an audiologist who specializes in cochlear implants. Using a strong early childhood curriculum as a foundation, The River School makes adaptations to accommodate children who are deaf and hard of hearing. These adjustments include: maximum class size of 8 to 12 students; a 1:4 ratio of children who are deaf and hard-of-hearing to children with normal hearing; two master’s level professionals in each room, one an educator, the other an SLP; language-enriched curriculum; individualized support; acoustically modified classrooms; and on-site audiology services. Children with normal hearing also benefit from these adaptations.

Child-directed activities are the hallmark of developmentally appropriate practice in early childhood education and, as a consequence, The River School classrooms are busy places. During much of the day, children are given choices between activities set up in the classroom. They are encouraged to participate in dramatic play, to engage in art activities and sensory experiences, to work cooperatively with peers in building and exploring, to engage in a literacy rich environment, and to become part of a group. Teachers and SLPs working with children who are deaf or hard of hearing in an inclusive classroom must be prepared to implement the child’s Individualized Education Program (IEP) goals during any activity that the child chooses. They can work on goals in the block corner, at the sensory table, at snack-time, or during an art activity.

Traditionally, deaf education programs have been designed with the expectation that children who are deaf need didactic language instruction. Modeling and imitation have been used as a teacher-directed, systematic method for teaching vocabulary, sentence structure, and articulation. This highly controlled strategy may no longer be necessary, given the ability of many children with hearing loss to learn incidentally. Instead, teachers can carefully select the activities provided, using environmental engineering an d thematic curriculum to ensure multiple opportunities to hear key vocabulary in context. Children who enter the classroom in the morning and are immersed in an airport, a pet shop, a pizza restaurant, or a fire station quickly absorb new vocabulary through repetition during play.

Creating an Optimal Environment

The River School building was renovated to provide 14 quiet classrooms. Ventilation output was moved to the hallways. Walls, doors, and acoustically treated glass panels in the hallways were installed along with carpeting to keep ambient noise low. In 2002 a full audiology suite was added to the lower level and in 2004 an audiologist joined our faculty to provide services to children with cochlear implants.

Classrooms where cooperative learning is a priority are challenging listening environments due to the presence of background noise. Small class sizes help decrease ambient noise, as do carpeting and soft surfaces. However, functioning in a noisy classroom is good practice for functioning in the real world. Children who can develop strategies to selectively attend to spoken language, to ask for and receive assistance when needed, and to position themselves to participate fully in classroom activities develop skills that will help them in many environments. Children are given assistance in learning how to make adjustments so that they can fully participate and advocate for themselves. Their development in this area is carefully monitored. Teachers also use appropriate pacing, intonation, and acoustic highlighting when speaking to children. They also routinely use visual support after auditory-only presentation, as well as pre-teaching and review strategies to ensure successful learning.

Why Inclusion?

Educating children who are newly implanted in inclusive settings provides a variety of advantages. The spoken language environment in mainstream classrooms provides a rich listening experience for children, with many opportunities for incidental learning. This has a positive impact on vocabulary and language development, which are both predictors of later literacy skills and associated with mainstream educational placement. Interaction with peers with normal hearing creates an ideal environment for social and behavioral development that promotes the use of spoken language and social skills.

Education in inclusive classrooms is distinctly different from learning skills in a treatment session. Skills learned in a treatment setting are sometimes poorly generalized to other situations. Children who function well in a quiet one-on-one interaction with a teacher or clinician often lose these skills once noise, distractions, and other children are introduced. Children who can acquire the same skills in a natural setting are advantaged in having multiple opportunities to practice and generalize their skills into the setting where they are to be used.

The inclusive philosophy is proactive: give children every support and then fade over time what is no longer needed. In The River School curriculum, careful attention is paid to developing language and supporting cognitive skills that underlie spoken language development such as attention, memory, motor sequencing abilities, oral motor development, and social behaviors. The program capitalizes on the window of opportunity available for optimally developing language and literacy skills by beginning at the youngest age possible. Phonological awareness skills are introduced at 18 months to lay the foundation for later reading and writing.

Successes

The River School model is proving effective in helping children at the school who have cochlear implants become age-appropriate users of spoken language. Since our opening in 2000 we have graduated children with cochlear implants who now attend mainstream schools without support.

Children who have had less optimal intervention are also progressing well although on a prolonged time frame. We still occasionally enroll children who are deaf and who have not been diagnosed until 2 or 3 years of age. These children typically require more intensive programming in addition to in-class intervention to close the gap between their language age and their chronological age. Such programming might include additional individual treatment, or intensive computer therapy to try to speed up the rate of progress.

About half of the children with hearing loss enrolled at The River School have progressed to a point where they are age-appropriate or above on language testing and require only minimal additional treatment or support. By first or second grade, children with deafness are typically reading at or above grade level. Children at the school who received cochlear implants close to their first birthday followed by early intervention services often have age-appropriate language skills by the time they are 2 or 3 years old. These children offer a glimpse of a best-case scenario for children born with deafness today. A longitudinal study which began in January 2000 at the The River School is underway to document the progress of children who are deaf as they achieve language and literacy milestones. The River School looks forward to continuing to tailor educational practice to keep pace with advancing technology.

Research Trends

Children who are deaf are now being identified earlier and are receiving cochlear implants at younger ages, many before their first birthday. Despite language delays, these children present with the potential to achieve educational outcomes commensurate with their hearing peers if given educational placements that are both appropriate and least restrictive. Inclusive classrooms with carefully crafted curriculum and highly trained faculty can support these children as they achieve language, cognitive, and social/emotional norms. Children with cochlear implants may require extra support for cognitive skills developing in concert with language, including attention and memory (Pisoni et al., 1999; see references online), and social support during everyday interactions with children with normal hearing.

Much has been written about the perceptual development of young children following implantation (Tomblin et al., 1999). Speech perception and production are regarded as primary benefits of cochlear implantation (Cheng, Grant, & Niparko, 1999; Geers, Brenner, & Davidson, 2003). As a consequence, early research on the developing skills of children with cochlear implants focused on these skills. Later research shifted to examine broader goals: language development, rate of language gain, literacy, and academic achievement. Early studies compared children with cochlear implants to children with deafness using other sensory aids (see Kirk, 2000 for a review), but in more recent research studies, children with hearing loss are no longer the comparison group. Current research is increasingly comparing children with cochlear implants to peers with normal hearing, reflecting heightened performance expectations empowered by technological advances and earlier identification and subsequent early implantation.

Language and literacy outcomes have shown a greater rate of improvement for children using cochlear implants than for children with similar hearing losses using hearing aids (Geers, 2003; Connor & Zwolan, 2004). In general, children with cochlear implants had superior scores on language achievement measures (Tomblin et al., 1999) and literacy (Connor & Zwolan, 2004). Given early implantation, these children are beginning to develop auditory skills and language at a similar rate to hearing peers (Robbins et al., 2004). There is even some evidence that with early implantation it is possible to accelerate the rate of language learning in order to close the gap between children’s chronological age and their demonstrated language age (Kirk et al., 2003). Although The River School provides intensive post-implant aural rehabilitation, the children in these studies had varying levels of intervention.

Francis and colleagues (1999) noted a trend toward mainstream educational placement and diminishing levels of support services required by children after implantation. They found that nearly 75% of children with cochlear implants were being educated in full-time mainstream placements some four years after surgery.